Temporal and Physiologic Measurements of Deglutition in the Upright and Supine Position with Videofluoroscopy (VFS) in Healthy Subjects.

Cross-sectional imaging has long been employed to examine swallowing in both the sagittal and axial planes. However, data regarding temporal swallow measures in the upright and supine positions are sparse, and none have employed the MBS impairment profile (MBSImP). We report temporal swallow measures, physiologic variables, and swallow safety of upright and supine swallowing in healthy subjects using videofluoroscopy (VFS). Twenty healthy subjects ages 21-40 underwent VFS study upright and supine. Subjects were viewed in the sagittal plane and swallowed 5 mL liquid and pudding barium. Oral transit time, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, and total swallow duration were measured. Penetration/aspiration scores and 14 MBSImP variables were analyzed in both positions. All subjects completed swallows supine, although one aspirated on one liquid bolus. Temporal measures of swallowing were similar for pudding upright and supine. Pharyngeal phase swallow measures were longer for liquids in supine. MBSImP physiologic measures revealed a pharyngeal delay in both positions. Although Pen/Asp range was higher supine, more subjects penetrated upright. Temporal measures were increased for liquids in supine. Although Pen/Asp range was higher in supine, more subjects penetrated upright. These results provide support for cross-sectional supine imaging of swallowing for pudding, but perhaps not thin liquids for dysphagic patients. Slightly thicker liquids might prove reliable in supine without compromising swallow safety. Future research should examine swallow physiology in both positions in dysphagic and older healthy subjects.

Scapular free flap harvest site: recognising the spectrum of radiographic post-operative appearance.

OBJECTIVE: Scapular free flap harvesting for oral cavity cancer reconstruction is an increasingly used and versatile option. We aim to describe the appearance of the scapula harvest site on chest radiograph and CT. METHODS: We retrospectively reviewed a surgical database of 82 patients who underwent scapular osteocutaneous flap harvesting for oral cavity cancer reconstruction and had imaging performed at our institution. We searched the picture archiving and communications system for all associated imaging. RESULTS: Characteristic radiographic appearance in the immediate post-operative period as well as in the remote post-operative period is described, including an upside-down V-shaped paraglenoid notch, rectangular (or triangular) lateral border defects and a sharply pointed inferior scapular body. Additionally, common CT appearances are discussed, including an abrupt gleno-scapular interval, an absent axillary rim bulge and a Z-shaped scapula. CONCLUSION: The altered appearance of the scapular defect following surgical harvest is easily recognised. Although the description of this defect may not alter management and may reasonably be omitted, a radiologist's comfort with these appearances may potentially enhance the understanding of patient management and recognition of superimposed complications, such as infection. ADVANCES IN KNOWLEDGE: Scapular osteocutaneous free flap reconstruction is an increasingly used technique after oral cavity surgery. Very few radiologists reported in our review the surgical scapular defects, and there is apparent ignorance of their appearance. We described characteristic radiographic and CT signs of scapular free flap harvesting to increase radiologists' familiarity with these defects, which may provide clinical information and possibly contribute to detection of complications.

Central venous catheter tip malposition.

Central venous catheters are commonly utilised to gain vascular access for varied clinical indications. Successful central venous catheter placement requires not only technical expertise, but also awareness of the potential complications. This article reviews the major procedural and post-procedural complications resulting from central venous catheter tip malposition.

Placement of tunnelled hemodialysis catheters across stenotic and occluded central veins.

PURPOSE. The purpose of this study was to evaluate the efficacy of placement of tunneled hemodialysis catheters in patients with occluded or stenotic central veins. MATERIALS AND METHODS. Data were prospectively collected for 26 patients (11 male, 15 female, mean age 52 years) referred for placement of tunneled hemodialysis catheters with central venous stenoses or occlusions. The central venous occlusions or stenoses were recanalized using traditional interventional catheter and guidewire techniques.
RESULTS. Thirty central venous access procedures were performed of which 28 (93%) procedures resulted in successful tunneled catheter insertion. Twenty-one internal jugular venous (13 right, 8 left) and 7 subclavian venous (3 right, 4 left) catheters were placed. Eighteen stenotic and 10 occluded venous segments were crossed including the brachiocephalic vein (n = 22), subclavian vein (n = 2), and the superior vena cava (4). One patient required insertion of a metallic stent to facilitate passage of the hemodialysis catheter across an occluded brachiocephalic vein. No procedure-related complications occurred. No episodes of upper extremity swelling or superior vena cava syndrome occurred following catheter insertion.
CONCLUSIONS. Insertion of tunneled hemodialysis catheter across occluded or stenotic central veins is technically feasible and safe. The use of occluded or stenotic central veins for catheter access preserves patent central veins for future shunt access.

Balloon-expandable common iliac artery occluder device for endovascular aneurysm repair.

This study was performed to evaluate the efficacy of a balloon-expandable Palmaz stent common iliac artery occluder device for endovascular stent-graft repair of aortoiliac aneurysms. Eighty-four patients (79 men, 5 women; age range 60-95 yr; mean age, 76 yr) with aortoiliac aneurysms underwent endovascular stent-graft repair. The repair consisted of a stent-graft extending from the abdominal aorta to the iliac or common femoral artery, a cross-femoral bypass graft, and an endovascular arterial occluder device within the contralateral common iliac artery. The occluder device consisted of a 5-cm segment of 6-mm diameter polytetrafluoroethylene (PTFE) graft with a purse-string suture occluding the leading end and a Palmaz stent sutured to the trailing end. The occluder device was delivered through a 17F catheter via an arteriotomy. Eighty-three of the 84 patients received aortic endografts. In one case, infrarenal aortic rupture occurred during deployment of the aortic stent requiring conversion to an open surgical repair. Initial technical success for occluder device insertion was achieved in 78 of the remaining 83 patients. Failure to advance the occluder device delivery sheath through a diseased iliac artery occurred in one patient. Common iliac artery rupture occurred during balloon expansion and occluder device deployment in two patients. Two patients required additional coil embolization of the common iliac artery adjacent to the occluder device at the time of stent-graft insertion to correct incomplete iliac occlusion. Delayed occluder device-related complications included one patient with a postoperative iliac endoleak who required percutaneous coil embolization and one patient with a postoperative iliac endoleak in whom a contained aortic aneurysm rupture developed that was treated by surgical ligation of the common iliac artery. Use of the Palmaz stent-based iliac artery occluder device is an effective technique to induce common iliac artery thrombosis to facilitate endoluminal stent-graft aneurysm repair.

Hepatic arterial complications in liver transplant recipients treated with pretransplantation chemoembolization for hepatocellular carcinoma.

PURPOSE: To compare the prevalence of hepatic arterial complications in patients who underwent hepatic arterial chemoembolization for hepatocellular carcinomas before orthotopic liver transplantation with the prevalence of hepatic arterial complications in the total population of liver transplant recipients. MATERIALS AND METHODS: Forty-seven patients underwent selective hepatic arterial chemoinfusion with mitomycin C, doxorubicin hydrochloride, and cisplatin combined with embolization. The prevalence rates for hepatic arterial complications, including pseudoaneurysm, stenosis, anastomotic disruption, and thrombosis, were tabulated and compared with results in 1,154 patients who underwent orthotopic liver transplantation but not chemoembolization. RESULTS: Of the 47 patients who had undergone preoperative hepatic arterial chemotherapy, 13% developed hepatic arterial complications within a mean of 7 days after transplantation; an 8% prevalence of hepatic arterial thrombosis was observed. Of the 1,154 patients who underwent orthotopic liver transplantation but not chemotherapy, 6% developed hepatic arterial complications; a 5% prevalence of hepatic arterial thrombosis was observed. There was no statistically significant difference in the prevalence rates for thrombosis and complications between the patients who underwent chemoembolization before orthotopic liver transplantation and those who did not. The mean interval between chemotherapy and orthotopic liver transplantation was 111 days (range, 3-428 days). CONCLUSION: Patients who undergo hepatic arterial chemotherapy are not at an increased risk of developing hepatic arterial thrombosis or other hepatic arterial complications after orthotopic liver transplantation.

Aortoiliac aneurysms: endoluminal repair--clinical evidence for a fully supported stent-graft.

PURPOSE: To evaluate aortoiliac aneurysms repaired with endovascular stent-grafts complicated by hemodynamically significant graft stenosis. MATERIALS AND METHODS: Fifty-four patients (52 men, two women; age range, 41-90 years; mean age, 75 years) with aneurysms of the infrarenal aorta (n = 36) or iliac artery (n = 18) underwent repair by means of placement of an endovascular stent-graft. Technical success was evaluated angiographically during and after placement. At follow-up (range, 12-44 months), all patients underwent sequential duplex ultrasonography, helical computed tomography, and physical examination. RESULTS: Stent-grafts were placed successfully in all cases. Stenosis at the internal iliac arterial origin was identified at angiography in 17 patients (31%). Supplemental intragraft stents were placed in 11 patients, and stent-graft angioplasty alone was performed in one patient. Intragraft stents were placed percutaneously in five patients when stenosis was discovered during follow-up. CONCLUSION: Supplemental intragraft stents were required in 31% of aortoiliac endovascular stent-grafts to correct stent-graft stenosis and preserve long-term function. Placement of a fully supported stent-graft is necessary to repair an aortoiliac aneurysm.

Central venous access: low internal jugular vein approach using imaging guidance.

OBJECTIVE: The use and safety of a low internal jugular vein cannulation technique for central venous access was prospectively evaluated. CONCLUSION: The inferior internal jugular vein provides a safe and direct route to the superior vena cava and right atrium for central venous access. Use of an internal jugular vein cannulation site at the base of the neck avoids kinking of tunneled and untunneled catheters.

Percutaneous renal biopsy complicated by renal capsular artery pseudoaneurysm.

We report a case of renal capsular artery pseudoaneurysm caused by percutaneous renal biopsy. The injury was diagnosed and treated with arteriography and transarterial embolization. Because the arterial injury was extraparenchymal, the clinical manifestations of blood loss were flank pain and decreasing hematocrit without hematuria. Injury to renal capsular arteries during percutaneous renal biopsy is a rare possibility because of their small size.

Venographic appearance of portosystemic collateral pathways.

Many imaging modalities can be used to evaluate various portosystemic collateral pathways seen in patients with portal hypertension. A knowledge of various typical and atypical pathways is essential for a proper understanding of the disease process. Transjugular transhepatic portographic appearance of such pathways are discussed in detail.

Atypical angiographic appearance of a superficial femoral artery mycotic aneurysm.

An unusual presentation of mycotic aneurysm is described. In this case, a large thrombosed mycotic aneurysm of the superficial femoral artery was associated with segmental occlusion of the adjacent artery. Small vessels were delineated in the periphery of the aneurysm on angiography.

Redesign for patient satisfaction.

In this era of changing health care systems, the word redesign is often linked with mergers, layoffs, or an economic move to balance the bottom line. Redesign is often perceived as a way to reduce the need for professional nurses by eliminating job functions. In this cost-cutting milieu, however, the most important factor--the patient--has been put aside. The article explores what factors contribute to patient satisfaction and describes the redesign process that was implemented at one institution to increase patients' satisfaction during hospitalization.